**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for one (Resident #78) of eight residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #78's rooms were in a position that was accessible to the residents. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. Findings included: Review of Resident #78's Face Sheet, dated 06/19/2024, reflected that resident was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included difficulty walking, unsteadiness of feet, and weakness. Review of Resident #78's Quarterly MDS Assessment, dated 04/19/2024, reflected Resident #78 had a moderate impairment in cognition with a BIMS score of 11. Resident #15 required moderate assistance for upper body dressing and lower body dressing. Review of Resident #78's Comprehensive Care Plan, dated 05/02/2024, reflected Resident #78 was at risk for falls related to poor balance and lack of coordination, and weakness and one of the interventions be sure the call light is within reach and encourage to use it to call for assistance as needed. Review of Resident #78's Joint Mobility Evaluation, dated 05/22/2024, reflected resident had limited range of motion to both shoulders, both elbows, and both wrists. Review of Resident #78's Fall Risk Assessment, dated 05/16/2024, reflected resident had a minimum risk for fall. Observation and interview with Resident #78 on 06/18/2024 at 11:25 AM revealed that Resident #78 was sitting at the side of her bed. Resident #78's call light was noted pinned between the bed and the wall. Resident #78 reached out her left arm and tried to pull the cord of the call light but stated she cannot pull it because it was trapped between the bed and the wall. She stated that whoever fixed her bed did not notice that the call light could not be accessed and was not able to pull it back to put it on top of the bed. She stated she would use her roommates call light if she needed assistance. She said the staff should put her call light where she could reach it because her arms were not strong enough to pull it. Observation on 06/19/20204 at 7:55 AM revealed that Resident #78 was sitting on her bed talking to a visitor. Her call light was still pinned between the bed and the wall and resident still cannot pull it. In an interview with CNA C on 06/19/2024 at 10:57 AM, CNA C stated she was assigned on Resident #78's hall. CNA C said she did her round at the start of her shift to check if any resident needed to be changed or transferred to the wheelchair. She said she also monitor if the call lights were with the residents. She said she did not notice that Resident #78's call light was pinned between the bed and the wall and cannot be pulled. She said Resident #78 seldom use the call light but said she must still make sure the call light was accessible when needed. She said call light must always be accessible because the residents use them to call the staff for any need and in cases of emergencies. CNA C added that if the call lights were not with the residents, the needs of the resident will not be known and addressed. She said she was responsible in ensuring the call lights were accessible for her assigned residents. She said she would her round and make sure the call lights were accessible to her assigned residents. In an interview with the DON on 06/19/2024 at 11:18 AM, the DON stated the call lights were inside the residents' rooms for a reason. He added the residents used the call lights to call for assistance, for a glass of water, for a pain medication, or for incontinent care. The DON added without the call lights, the residents would not be able to tell the staff what they needed and eventually their needs would not be met. The DON further added when the residents cannot pull or access their call lights, unfavorable incidents like falls, minor hurts, or major injuries could happen. The DON said the expectation was for the staff to ensure that the call lights were within reach of the residents at all times. The DON concluded that moving forward, he would educate the staff of the importance of call lights for the residents and would include the issue on their morning meeting. In an interview with LVN A on 06/20/2024 at 7:32 AM, LVN A stated call lights should be within the reach of the residents at all times. LVN A said the call lights should not be in position where the resident cannot pull it or access it. She said for some residents, the call light was their sense of protection that if something happened to them, they would be able to call the staff for help. She said the residents also use the call lights if they needed to be changed or they needed a pain medication. LVN A said the residents might fall trying to get up and get what they needed. LVN A said everybody was responsible in making sure the call lights were with the residents, whether the resident was independent or not. She said she would check her rooms to see if the residents had their call lights Record review of facility's policy Call Light/Bell Policy/Procedure - Nursing Clinical revised 05/2007 revealed, Policy: It is the policy of this facility to provide the resident a means of communication with nursing staff . Procedures . 5 . Place the call device withing resident's reach before leaving room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents ' choices for 1 (Resident #46) of 1 resident reviewed. for quality of care. The facility failed to to obtain physician orders and assess Resident #46 for a scoop mattress and obtain physician orders prior to installing the scoop mattress. This failure could prevent the resident to be free from of any physical or chemical restraints. Findings included: Record review of Resident #46's Face Sheet, dated 06/19/2024, revealed she was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included unspecified dementia (memory decline), lack of coordination, and repeated falls. Record review of Resident #46's Quarterly Minimum Data Set (MDS) dated [DATE] revealed, she had a Brief Interview for Mental Status (BIMS) score of 06 (severe cognitive impairment) and for ADL care it stated, for transfers, toileting, and bathing, the resident required moderate assistance. Record review of Resident #46's physician orders dated 06/19/24 revealed no orders for a scoop mattress. Observation on 06/18/24 at 11:03 AM of Resident #46's bed revealed she was observed having a scoop mattress. An interview and observation on 06/19/24 at 10:00 AM with LVN L, she stated she was the nurse for Resident #46. She stated the resident is totally independent and did not require assistance to get into or out of her bed. She stated the resident should not have a scoop mattress. LVN L went into Resident #46's room and observed that the resident did have a scoop mattress on her bed. She stated she was not sure how the resident got the mattress. She stated the resident had just changed rooms and they may have just left the scoop mattress and not replace it. She stated the risk of the resident having the scoop mattress without physician orders or an assessment could result in the result having a fall when trying to get into and out of bed. An interview on 06/20/24 at 10:45 AM with the DON, he stated he was made aware of Resident #46 having a scoop mattress. He stated the residents had recently changed rooms and when the resident was moved into the room, staff failed to change the mattress. He stated they have since changed out the mattress to a more appropriate one. He stated the risk of the resident having a scoop mattress could result in her injuring herself. Record review of facility policy on Physician orders, dated 08/2007, stated It is the policy of this facility to ensure that no resident is placed in physical restraints for the purpose of discipline or convenience and that restraints are only applied to treat the resident's medical symptoms. All residents requiring physical restrains will be assessed for least restrictive measures prior to restraint application and restraints will be reduced as appropriate to the resident's medical condition. No resident will have a physical restraint placed for positioning purposes unless there is clearly no other alternative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that Residents, who needed respiratory care, was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 (Resident #321 and Resident #322) of ten residents reviewed for respiratory care. The facility failed to ensure Resident #321's nebulizer masks and nasal cannula was properly stored. The facility failed to ensure Resident #322's nasal cannula was properly stored. The facility failed to ensure a Physician's Order was in place for Resident #322's oxygen administration. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met. Findings included: Resident #321 Review of Resident #321's Face Sheet, dated 06/19/2024, reflected that resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) with exacerbation and acute respiratory failure with hypoxia (insufficient amount of oxygen in the body). Review of Resident #321's Comprehensive MDS Assessment, dated 06/08/2024, reflected resident had a severe impairment in cognition with a BIMS score of 07. The Comprehensive MDS Assessment indicated Resident #321's primary medical condition was chronic obstructive pulmonary disease with exacerbation. Review of Resident #321's Comprehensive Care Plan, dated 06/08/2024, reflected resident had an altered cardiovascular status related to COPD (chronic obstructive pulmonary disease) and respiratory failure and the interventions were to administer nebulizer treatment and oxygen as ordered. Review of Resident 321's Physician Order, dated 06/04/2024, reflected, Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML. 1 vial inhale orally three times a day for wheezing, sob (shortness of breath). Review of Resident 321's Physician Order, dated 06/18/2024, reflected, O2 AT 2-4 L/MIN CONTINUOUS PER via NC, every shift. Observation and interview with Resident #321 on 06/18/2024 at 9:40 AM revealed that Resident #321 was on her bed resting. Resident #321 was on oxygen administration via nasal cannula. It was also noted that her mask for breathing treatment was on top of the side table. The breathing mask was not bagged. Resident #321 also had a portable oxygen tank at the back of her wheelchair. A nasal cannula was attached to the portable oxygen tank. The tubing of the nasal cannula was hanging on the backrest of the wheelchair with the prongs of the nasal cannula touching the seat of the wheelchair. The nasal cannula was not bagged. According to the resident, she had breathing treatment every morning. She said the nurse would put it on and would take it off. Observation and interview with CNA B on 06/19/2024 at 7:51 AM, CNA B stated the Resident #321's nasal cannula was hanging at the backrest of her wheelchair. She said the nasal cannula should not be hanging and touching the wheelchair because the wheelchair could be dirty. She said it should be bagged when the resident was not using it so the nasal cannula will not be contaminated. She said whoever assist the resident from transferring from wheelchair to bed should put the nasal cannula in a bag. CNA B went inside the room to get the nasal cannula but then stopped halfway and said she would call the nurse to replace the nasal cannula. Observation and interview with LVN A on 06/19/2024 at 8:38 AM, LVN A stated the breathing mask and the nasal cannula should not have been exposed nor touching anything because it could cause contamination and possible infection. LVN A said the breathing mask and the nasal cannula should be bagged when not in use. LVN A went to Resident #321's room and saw the nasal cannula at the back of the wheelchair. LVN A disconnected the nasal cannula from the portable oxygen and threw it on the trash can. She said she would get a new nasal cannula for Resident #321. She said she would also change Resident #321's breathing mask because it was placed on top of the table. Resident #322 Review of Resident #322's Face Sheet dated 06/19/2024 reflected that resident was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia (long term condition where the lungs cannot get enough oxygen into the blood). Review of Resident #322's Care Plan on 06/19/2024 reflected no care plan for oxygen administration. Review of Resident #322's Physician Order on 06/19/2024 revealed no Physician Order for oxygen administration. Observation and interview with Resident #322 on 06/18/2024 at 9:48 AM revealed Resident #322 was on her bed, resting. It was noted that the resident had an oxygen concentrator at bedside. The oxygen concentrator was off. A nasal cannula was connected to the oxygen concentrator. The nasal cannula was hanging on top of the concentrator and was not bagged. Resident #322 stated she only use the oxygen if she needed it, like if she was having a hard time to breath. She said she had no recollection when was the last time she used her oxygen. Observation and interview with LVN A on 06/19/2024 at 8:41 AM, after coming out of Resident #321's room, LVN A then went to Resident #322's room and saw the nasal cannula hanging on the oxygen concentrator. LVN A disconnected the nasal cannula hanging on the oxygen concentrator and threw it on the trash can. She went to the supply room to get a new nasal cannula, a breathing mask, and plastic bags. LVN A stated she needed to change the nasal cannula and the breathing mask to prevent any respiratory infection. Observation and interview with LVN A on 06/20/2024 at 8:12 AM, LVN A stated Resident #322's order for oxygen was PRN. She logged on to her laptop to verify the order. LVN A said there was no order for oxygen. She said there should be an order for Resident #322's oxygen supplement so the staff would know that the resident had respiratory needs. She said the order for oxygen should be reflected on the resident's physician orders on the system. LVN A said since resident #322 as her resident, she was responsible in putting in the order for oxygen. She added she would put in the order and then started typing the order in the system. In an interview with the DON on 06/19/2024 at 11:18 AM, the DON stated the breathing mask and the nasal cannula should be bagged when not in use. The DON said it was the proper way to store the breathing mask and the nasal cannula. He said if those breathing apparatus were not bagged, exposed, or touching surfaces that were not clean, then oxygen administration could be compromised. The DON said it could also result to contamination and infection. He said the staff, including him, were responsible for monitoring that the nasal cannula and the breathing mask were bagged when not in use. He said that if a resident was using some oxygen, there should be an order specific for oxygen concentration to reflect the amount of oxygen, the duration, and the delivery device. He said the order is essential so the staff would be on the same page in caring for the respiratory need of the resident. He said without the order, the respiratory need of the resident will not be met. He said the expectation was for the breathing mask and the nasal cannula would be stored properly. He continued that another expectation was the staff to put the order on the system if there was an order for oxygen administration. The DON concluded that moving forward, he would educate the staff and would continually remind them to be diligent in making sure the procedures for respiratory care were followed. Record review of facility's policy, Oxygen Administration Nursing Manual - Nursing Care rev. 06/2020 revealed Purpose: To prevent or reverse hypoxemia and provide oxygen to the tissues . III. Infection Control . A. All oxygen tubing, humidifiers, masks, and cannulas . B. Oxygen items will be stored in a plastic bag at the resident's bedside to protect the equipment from dust and dirt when not in use. Record review of facility's policy, Physician's Order, Telephone Orders and Recapitulation Process revised 11/2007 revealed, Policy: 1. Physician's orders shall be obtained prior to the initiation of any medication or treatment . Guidelines . 1 . order to the facility is necessary to show that the resident was admitted by a physician to this level of care . b.) Medication (Name, strength/dose, frequency, route of administration, diagnosis, PRN is to include specific reason).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #49 and Resident #89) of eight residents observed for infection control. The facility failed to ensure that CNA D changed his gloves and perform hand hygiene while providing incontinent care to Resident #49 and Resident #89. This failure could place the residents at risk of cross-contamination and development of infection. Findings included: Resident #49 Review of Resident #49's Face Sheet, dated 06/19/2024, reflected resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included hemiplegia (paralysis of one side of the body) and weakness. Review of Resident #49's Comprehensive MDS Assessment, dated 04/13/2024, reflected Resident #49 had a severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated Resident #49 was always incontinent for bowel and bladder. Review of Resident #49's Comprehensive Care Plan, dated 06/06/2024, reflected resident was incontinent of bowel and bladder related to impaired mobility and one of the interventions was to wash, rinse, and dry perineum (the space between the anus and the genitals). Observation on 06/18/2024 at 10:27 AM revealed CNA D was about to transfer Resident #49 to bed from the shower chair via mechanical lift. While waiting to be transferred, Resident #49 had a bowel movement and soiled the Hoyer sling. CNA D put on some gloves and continued to transfer the resident with the assistance of another staff. He did not wash his hands before putting on the gloves. After the transfer, CNA D rolled the resident towards the wall, rolled the soiled Hoyer sling and bed padding towards the center of the bed and tucked them under the resident. After tucking the soiled Hoyer sling and padding, CNA D took the new brief and placed it at the side of the resident. He did not change his gloves nor sanitized his hands before touching the new brief. CNA D then cleaned the resident's bottom. After cleaning the resident's bottom, CNA D took the new brief and put it under the resident's bottom and then rolled back the resident. He did not change his gloves nor sanitized his hands before putting the new brief on the resident's bottom. He then pulled the soiled Hoyer sling and padding, fixed the brief, and taped it on both sides. He took off his gloves but did not wash his hands after the incontinent care. Resident #89 Review of Resident #89's Face Sheet, dated 06/19/2024, reflected resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included hemiplegia and weakness. Review of Resident #89's Comprehensive MDS Assessment, dated 04/13/2024, reflected Resident #49 had a severe impairment in cognition with a BIMS score of 06. The Comprehensive MDS Assessment indicated Resident #89 was always incontinent for bowel and bladder. Review of Resident #89's Comprehensive Care Plan, dated 04/22/2024, reflected resident had an ADL self-care performance deficit related to CVA (cerebrovascular disease: stroke) and one of the interventions was for staff to assist with ADLs with needed assistance. Observation on 06/18/2024 at 10:59 AM revealed CNA D was about to transfer Resident #89 to his wheelchair. CNA D stated he would clean the resident first and change his clothes. CNA D put on his gloves. He did not wash his hands before putting on his gloves. CNA D unfastened the tape on both sides of the brief, pushed it between the legs of the resident, then rolled the resident to one side. He then proceeded to clean the resident's bottom. After cleaning the resident's bottom, CNA D pulled the soiled brief. He then changed his gloves but did not sanitize his hands. CNA D then took the new brief that was placed on the side of the resident's leg. The brief fell on the floor. CNA D picked it up and placed it on the resident's bottom. CNA D did not get another brief to replace the brief that fell on the floor. CNA D instructed and assisted the resident to roll back. CNA D then cleaned the front part of the resident, pulled the front part of the brief, and taped it on both sides. CNA D did not change his gloves nor sanitize his hands after cleaning the front part of the resident and before touching the new brief again. He then went to the resident's drawer to get new shorts. CNA D did not change his gloves nor sanitize his hands before touching the clean shorts. CNA D then took off the resident's hospital gown and put on the t-shirt that was prepared earlier and the shorts that was taken from the resident's drawer. CNA D took off his gloves and threw them in the trash can. He did not wash his hands after incontinent care. In an interview with CNA D on 06/18/2024 at 1:40 PM, CNA D stated he did not wash his hands before and after cleaning Resident #49 and Resident #89 but did put on new gloves before doing incontinent care. CNA D acknowledged that he did not change his gloves after cleaning the residents and before touching the new brief. He said he should had taken off his gloves, washed or sanitized his hands, and then put on new gloves after cleaning the resident and before getting the new brief. He said he should have replaced the brief that fell on the floor. He said not washing the hands before and after incontinent care, not changing the gloves before touching the new brief and clothes, not sanitizing the hands in between changing of gloves, and not replacing the brief that fell on the floor could cause cross contamination and infection. He said they do have in-services for infection control, handwashing, and incontinent care always. In an interview with the DON on 06/19/2024 at 11:18 AM, the DON stated he was made aware by the CNA involved about the infection control issue during incontinent care. The DON said every staff should wash their hands before and after every care. He said gloves should be changed and the hands should be sanitized after cleaning the resident's buttocks or the resident's front part before touching the any clean items. He said not washing the hands, not changing the gloves, and not sanitizing the hands in between changing of gloves could result to cross contamination and infection. The DON also added if the brief had fallen to the floor, it should not be used anymore for a simple reason that it was already dirty. The DON said the expectation was for the staff would remember to wash their hands and change their gloves when transitioning from a dirty area to a clean area, sanitize their hand when changing their gloves, and not to use items that had fallen to the floor. The DON said he already did a one-on-one in-service with CNA D but would do an infection control in-service for all the staff. He concluded that he would continually remind the staff to be attentive to the procedures for infection control and that he would personally monitor infection control. In an interview with LVN A on 06/20/2024 at 7:32 AM, LVN A stated the right procedure was to wash the hands and change the gloves after cleaning the bottom of the resident and before getting the new brief. She said the purpose of the method was to prevent cross contaminations and infections. She said microorganism could easily transfer if the gloves were not changed throughout incontinent care. LVN A added microorganisms could transfer from the soiled gloves to the new brief as well as to the clothes of the resident. She also said the brief should have been replaced because it already fell on the floor. She said the CNA should have not picked it up in the first place. She said she would remind the CNAs on her hall about the importance of washing hands before and after every care, changing gloves from dirty area to clean area, and sanitizing the hands in between changing of gloves. Record review of facility's policy, Hand Hygiene Infection Control Prevention and Control Program revealed Policy: This facility considers hand hygiene the primary means to prevent the spread of infections . b. Before and after direct contact with residents . h. Before moving from a contaminated body site to a clean body site during resident care . i. After contact with a resident's intact skin . j. After contact with blood or bodily fluids . m. After removing gloves . hand hygiene is the final step. Record review of facility's policy, Infection Control Prevention and Control Program revealed Policy: The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program . Goals: Promote individual resident's rights and well-being while trying to prevent and control the spread of infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for areas in the facility for 6 (Resident room [ROOM NUMBER], #513, #515, #517, #519, and #522) of 14 resident rooms observed for a safe, clean, comfortable, and homelike environment. The facility failed to ensure that Residents room [ROOM NUMBER], #513, #515, #517, #519, and #522 were cleaned and sanitized. This deficient practice could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. Findings included: An observation on 06/18/24 at 10:50 AM of Resident room [ROOM NUMBER]'s reflected the air conditioning located in the room had dirt particles and black dirt grime on the top and between the vents of the units. The air filters had a thick layer of dust on them. One of the two lights in the resident bathroom was out. The corners of the bathroom floor had built up thick dirt and grime. An observation on 06/18/24 at 10:54 AM of Resident room [ROOM NUMBER] reflected the air conditioning located in the room had dirt particles and black dirt grime on the top and between the vents of the units. The air filters had a thick layer of dust on them. The corners of the bathroom floor had built up thick dirt and grime. The faucet on the bathroom sink had thick built up calcium deposits along the base of the faucet. An observation on 06/18/24 at 10:58 AM of Resident room [ROOM NUMBER] reflected the air conditioning located in the room had dirt particles and black dirt grime on the top and between the vents of the units. The air filters had a thick layer of dust on them. The corners of the bathroom floor had built up thick dirt and grime. The faucet on the bathroom sink had thick built-up calcium deposits along the base of the faucet. The top of one of the nightstands had thick milky stains all over the top of it. An observation on 06/18/24 at 11:02 AM of Resident room [ROOM NUMBER] reflected the air conditioning located in the room had dirt particles and black dirt grime on the top and between the vents of the units. The air filters had a thick layer of dust on them. An observation on 06/18/24 at 11:04 AM of Resident room [ROOM NUMBER] reflected the air conditioning located in the room had dirt particles and black dirt grime on the top and between the vents of the units. The air filters had a thick layer of dust on them. The corners of the bathroom floor had built up thick dirt and grime. The faucet on the bathroom sink had thick built-up calcium deposits along the base of the faucet. An observation on 06/18/24 at 11:07 AM of Resident room [ROOM NUMBER] reflected the air conditioning located in the room had dirt particles and black dirt grime on the top and between the vents of the units. The air filters had a thick layer of dust on them. The airduct along the wall had black dirt stains. An interview on 06/19/24 at 1:33 PM with Housekeeping D, she stated she had been at the facility for 18 months. She stated that when she first started, she was told to pick up trash, mop and sweep floor, wipe down doors, windowsills, and the nightstands. She stated they are supposed to clean the air conditioner unit. She stated they are supposed to clean the outer part of the unit. She stated that she thinks maintenance cleans the air filters. She was shown pictures of the concerns observed in the resident room [ROOM NUMBER], #513, #515, #517, #519, and #522, and she stated that maintenance was needed to replace the heavily stained faucets, fix the tiles, and clean the air filters. She stated she would get someone from maintenance to clean the air filters. She stated the housekeeping supervisor was on vacation this week and she was in charge until their return. She stated the risk of the filters not being cleaned thoroughly could prevent the resident from getting fresh air. An Interview on 06/19/24 at 1:46 PM with the Maintenance Director, he stated he had been at the facility for two years. He stated maintenance was supposed to change the air filters quarterly. He stated housekeeping was supposed to clean the air filters in the air condition unit in the rooms while they are cleaning the unit itself. He was shown pictures of the concerns observed in rooms #511, #513, #515, #517, #519, and #522, he stated that maintenance only cleans the unit in the ceiling and the main unit. He stated he would coordinate with housekeeping to ensure that the filters in the 500-hall were cleaned. He was advised of the faucets in the resident rooms that had a lot of calcium buildup. He stated the risk of the air condition units not being cleaned thoroughly could cause medical issues for the resident. Review of the facility's policy on Safe/Comfortable/Homelike Environment (Revised 2022) reflected Housekeeping and Maintenance services include the cleaning, sanitization, and care for rooms and common areas of the facility to ensure that the facility is safe for all who reside, work, and visit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food storage, labeling, dating, and kitchen sanitation. The facility failed to ensure food in the facility's refrigerator, was labeled and dated according to guidelines. The facility failed to ensure food in the facility's freezer, was labeled and dated according to guidelines. The facility failed to ensure the ice machine scoop holder, located in the facility's kitchen, was cleaned. The facility failed to ensure kitchen equipment (storage bins) was cleaned and sanitary. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings included: Observations on 06/18/24 from 09:05 AM to 09:25 AM in the facility's only kitchen reflected: Observation of the ice machine, in the facility kitchen revealed the ice scoop was stored in a blue container, and the bottom of the containers had black stains in it. Two large white storage bins containing sugar and flour had black dirt stains along the outer and inner entrance of the container. The sugar had black particles in it. Two medium white storage bins containing brown sugar and rice had black dirt stains along the outer and inner entrance of the containers. One large bag of bread sticks with the date 6/17, and there was no other expiration or discatrd date. Facility policy dictates that the month, day and year should be listed, not just day and month. One bag of large pretzels with the date 6/7 and there was no other expiration or discatrd date. Facility policy dictates that the month, day and year should be listed, not just day and month 10 large frozen tubes of meat were unlabeled undated. The items apppeared to be in its original package but there were no visible label indicating the type of meat and date items were receiverd. An interview on 06/19/24 at 1:00 PM with the Dietary Manager and the dietitian, they were advised of the findings in the kitchen. The Dietary Manager advised that she had made all the corrections that were observed during the initial walkthrough on 06/18/24. The Dietary Manager advised that she had dropped the ball in ensuring that the foods were stored, labeled, and dated correctly. She stated that all of the items mentioned should include the full [NAME] day and year when labeling items being stored upon arrival. The DM stated that she would in-service her team on proper labeloinng and dating items upon arrival and ensure the bins are checked for cleanliness for frequently. They advised the risk of these concerns not being addressed could result in cross contamination and airborne illnesses. An interview on 06/20/24 at 10:45 AM with the DON, he was made aware of the findings in the kitchen. He stated that he expects his kitchen staff to meet all required expectations. He stated the risk of the concerns not being addressed could result in residents getting sick. Record Review of the Facility's policy on Food Storage dated 08/2007, revealed It is the policy of this facility that food storage areas shall be maintained in a clean, safe, and sanitary manner. 1. Food storage areas shall be clean at all times. Review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under § 3-202.18. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306.

Based on observations, interview, and record review, the facility failed to maintain an infection prevention and control program that must include, at a minimum, written standards, policies, and procedures for the program which included standard and transmission-based precautions to be followed to prevent spread of infections for one (LVN C) of seven staff reviewed for infection control. LVN C failed to perform hand hygiene between glove changes as he checked blood sugars and provided insulin for Resident #1. This failure could affect residents by placing them at risk for the spread of infection. Findings included: An observation on 08/18/23 at 11:22 AM of LVN C performing a blood sugar check and insulin medication administration for Resident #1 revealed LVN C washed his hands with soap and water and donned gloves after he entered the resident's room. LVN C used an alcohol pad to cleanse the finger of Resident #1 and allowed it to dry. LVN C using a single use needle pricked the finger to Resident #1's right hand and applied a drop of blood to the glucometer test strip and noted a glucometer blood sugar reading of 111 mg/dL. LVN C disposed of lancelet, test strip, and gloves. Without performing hand hygiene, LVN C donned new gloves and disinfected the glucometer with disinfectant wipes and allowed it to dry before returning it to the medication cart. LVN C disposed of his gloves and the disinfectant wipes. Without performing hand hygiene LVN C donned new gloves and removed Resident #1's Insulin Flexpen from the medication cart, verified the physician's medication order and prepared Resident #1's insulin for administration. LVN C took the resident's Insulin Flexpen into Resident #1's room, Resident #1 exposed her abdomen, and with an alcohol pad LVN C cleansed the skin to Resident #1's left lower abdomen and allowed to air dry. LVN C administered the insulin medication to Resident #1's left lower abdomen quadrant. LVN C disposed of the Insulin Flexpen needle, disinfected the resident's Insulin Flexpen with an alcohol pad, removed his gloves and sanitized his hands with ABHR. In an interview on 08/18/23 at 11:34 AM LVN C stated he should perform hand hygiene by either washing his hands with soap and water and or by using ABHR before and after care and when changing his gloves. LVN C stated he performed hand hygiene initially when he entered Resident #1's room but not when changing gloves during the resident's care. LVN C stated it was important to perform hand hygiene when changing gloves to reduce the risk infection to a resident. In an interview on 08/21/23 at 12:00 PM the DON stated staff should perform hand hygiene at the beginning of any task by hand washing or the use of ABHR. The DON stated hand hygiene should also be performed by staff during a task before putting on new gloves, when gloves and or hands were visibly soiled, and when staff were in contact with bodily fluids like blood. The DON stated LVN C should have performed hand hygiene each time he changed his gloves to prevent the risk of infection to the resident. Review of facility policy titled; Hand Hygiene revised 10/2022 reflected It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene based on accepted standards. Purpose: Hand hygiene is one of the most effective measures to prevent the spread of infection .Procedure .2. Use alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations .b. Before and after direct contact with residents; c. Before preparing or handling medications .m. After removing gloves .r. After removing and disposing of personal protective equipment

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for one (Residents #1) of six residents reviewed for clinical records. RN A and LVN B failed to document on Resident #1's August 2023 Medication Administration Record accurate medication times of her insulin on the following dates: 08/01/23, 08/02/3, 08/05/23, 08/06/23,08/07/23, 08/08/23,08/10/23, 08/11/23, 08/12/23,08/13/23, 08/14/23, and 08/15/23. This failure could place residents at risk for inaccurately documented medical records. Findings included: Review of Resident #1's Face Sheet, dated 08/21/23, revealed the resident was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses cognitive communication deficit and type 1 diabetes. Review of Resident #1's Quarterly MDS assessment, dated 07/21/23, reflected Resident #1 had a BIMs score of 15 indicating she was cognitively intact. She had diagnoses of stroke, diabetes, hyperglycemia (high blood sugar), and cognitive communication deficit. Review of Resident #1's Care Plan dated 08/21/23 reflected she had diabetes Mellitus and would have no complicates related to diabetes through target date 09/03/23. Review of Resident #1's Physician's Orders dated 08/21/23 revealed the following physician's orders: Insulin Glargine inject 25 units subcutaneously in the morning scheduled at 08:00 AM for Diabetes Mellitus, order dated 06/11/23; discontinue date 08/06/23. Insulin Aspart inject 6 units subcutaneously one time a day before meals with lunch scheduled at 12:00 PM related to hyperglycemia, order date 03/11/23. Insulin Aspart inject 4 units subcutaneously one time a day before meals with dinner scheduled at 05:00 PM related to hyperglycemia, order date 03/11/23. Insulin Aspart inject as per sliding scaled if 151-200=2units; 201-250=4 units; 251-300=6 units; 301-350=8 units; 351-999=10 units; subcutaneously before meals scheduled at 06:30 AM, 11:30 AM, 04:30 PM, and at bed time scheduled at 09:00 PM related to type 1 Diabetes Mellitus order date 03/11/23. Review of Resident #1's facility Medication Administration Records for August 2023 reflected: RN A documented Resident #1's scheduled 08:00 AM dose of Insulin Glargine 25 units was administered on 08/06/23 at 09:24 AM. RN A documented Resident #1's scheduled 12:00 PM dose of Insulin Apart 4 units was administered on 08/13/23 at 02:03 PM. RN A documented Resident #1's scheduled 06:30 AM dose of Insulin Aspart per sliding scale was administered on 08/05/23 at 07:38 AM, the scheduled 08/12/23 dose was administered at 08:19 AM, and the scheduled 08/06/23 dose was administered at 09:24 AM; the scheduled 11:30 AM dose was administered at 12:52 PM. LVN B documented Resident #1's scheduled 05:00 PM dose of Inulin Apart 4 units before dinner was administered on 08/01/23 at 10:21 PM, the scheduled 08/02/23 dose was administered at 06:48 PM, the scheduled 08/07/23 dose was administered at 06:49 PM, the scheduled 08/08/23 dose was administered at 09:52 PM, the scheduled 08/10/23 dose was administered at 06:56 PM, the scheduled 08/11/23 dose was administered at 10:03 PM. LVN B documented Resident # 1's scheduled 04:30 PM dose of Insulin Aspart per sliding scale was administered on 08/08/23 at 09:51 PM, the scheduled 08/09/23 dose was administered at 06:07 PM, the scheduled 08/11/23 dose was administered at 10:02 PM, the scheduled 08/14/23 dose was administered at 06:05 PM, and the scheduled 08/15/23 dose was administered at 06:21 PM; the scheduled dose at 09:00 PM was administered at 10:30 PM. In an interview on 08/18/23 at 10:02 AM Resident #1 stated she received her insulins sometimes before, at times after a meal, and bedtime. Resident #1 stated the times she was served her meals varied and facility staff were to provide her insulins right before she ate a meal. Resident #1 stated she explained to staff her insulins should be given right before she ate which never happened. In an interview on 08/21/23 at 08:21 AM RN A stated she was aware of Resident #1's scheduled medication administration times by checking the resident's medication administration record. RN A stated with Resident #1's insulin she had to provide it to the resident at the specified time the medication administration record indicated it was due. RN A stated he had to administer Resident #1's insulin within 15 minutes before she received her meals. RN A stated immediately after she administered insulin, she should have documented on the resident's medical administration record it was given. RN A stated at times she had documented the administration of Resident #1's insulin 30 minutes beyond its scheduled time as she had to wait on her meal to be ready. RN A stated without looking at the specific August 2023 medication administration record for Resident #1 she could not remember the times she charted Resident #'1s administration of insulin. RNA stated she had administered Resident #1's insulins timely but documented the administration times late on her medication administration record. RN A stated at times if she had charted beyond the 30 minutes after a scheduled dose of insulin was due for Resident #1 she could have been called away to do something and documented the insulin as administered later in her shift because she was busy. RN A stated she had administered medication late to Resident #1 and the risk of documenting Resident #1's insulin administration late would be it could be considered a medication error because the resident's medication needed to be administered per physician's orders. In an interview on 08/21/23 at 08:41 AM LVN B stated she was aware of when a resident's insulin was to be administered by checking the medication administration record. LVN B stated she was to provide a resident's insulin 10 minutes before a meal was served. LVN B stated she had administered Resident #1's insulin each time she worked with the resident within the scheduled time as indicated on the resident's medication administration record, she then wrote the time she administered the medication on a paper and documented it in the electronic medication administration record later in her shift. LVN B stated in those instances where she documented in Resident #1's electronic medical record late administration times of insulin she had been called away from the task of documentation for reasons like a resident had fallen, she had an admission, or an incident had occurred keeping her from documenting in real time. LVN B stated the risk of late documentation would indicate she had not administered Resident #1's medication as physician ordered. In an interview on 08/21/23 at 09:57 AM Resident #1's attending physician stated facility staff should instantly document the administration of Resident #1's medication in her medication record as they had given her scheduled doses of insulin. He stated he had no indication staff were not administering Resident #1's insulins timely but discussed with the facility as part of the Quality Assurance meeting the issue of staff completing their medication pass for Resident #1 and then documenting the administration later in the shift. In an interview on 08/21/23 at 12:00 PM the DON stated when staff administered Resident #1's insulin they should immediately document in the resident's electronic medication record that the task had been completed. The DON stated he had encountered times in which Resident #1's insulin administration had not been documented timely by staff. The DON stated there were instances in which nursing staff were delayed from documenting real time administration of insulins because they may have to retrieve a meal from the dining room. The DON stated RN A and LVN B should have documented the administration of Resident #1's insulin immediately after providing it to her and not later in their shift. The DON stated in some instances nursing staff failed to document in the moment when they had administered a resident's insulin because they could become busy with caring for a resident that had fallen or displayed behaviors related to dementia and document later in the shift their administration of a resident's insulin. The DON stated if RN A and LVN B should have requested assistance from other staff to respond to situations that may have distracted them from documenting immediately the administration of Resident #1's insulin. The DON stated the risk of not documenting the timely administration of a resident's insulin was it would indicate in a resident's medical record the inaccurate administration of medications. Review of facility policy titled, Policy/Procedure-Nursing Clinical Section: Medication Administration revised 05/2007 reflected . Policy: It is the policy of this facility that medications shall be administer as prescribed [NAME] the attending physician. Procedures .7. Medications may not be set up in advance and must be administered within one (1) hour before or after their prescribed time. NOTE: Before and/or after meal orders must be administered as orders .13. The nurse must enter an explanatory note on the reverse side of the Medication Administration Record when drugs are withheld, refused, or given other than at scheduled times .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment along with to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #1) of 4 residents observed for infection control. The facility failed to remove soiled bed linens from Resident #1's bed. This failure could place residents at risk for the spread of infection. Findings included: Observation on 6/27/23 at 9:57am during the surveyor's initial observation of the Alzheimer unit, surveyor smelled a foul odor and observed multiple dry brown stains covering a large portion of the sheet on the Resident #1's bed sheets. Record review of Resident #'1's face sheet revealed a [AGE] year-old female with a current admit date of 2/3/2021. Her diagnoses included unspecified dementia, unspecified severity, with other behavioral disturbances, unsteadiness on feet, generalized anxiety disorder, muscle weakness, cognitive communication deficit, delusional disorders, and major depressive disorder. Record review of Resident #1's MDS dated [DATE] revealed resident was unable to complete a BIMS due to cognitive impairment. The MDS revealed the resident required extensive assistance from staff with transfers, bed mobility, transfers, dressing, toileting, and personal hygiene. Interview with Aide A assigned to Resident #1's room on 6/27/23 at 1:06pm, revealed the resident was incontinent of bowel and bladder. Aide A revealed the aides are responsible to change linens. Aide A revealed she was unaware of when Resident # last slept in the bed and when Resident #1's room was last cleaned. Aide A revealed when a resident's bed had soiled linens the soiled linens needed to be taken off, the Aide needed to clean the bed and then make the bed. Aide A revealed the risk of leaving soiled linens on a bed could cause a resident to be sick. Aide A revealed the linens were changed routinely and as needed. Aide A revealed the residents that were on hospice had a hospice aide that came Monday-Friday for showers and changed the bed linens. Interview with LVN on 6/27/23 at 1:15pm LVN revealed Resident#1 was bowel and bladder incontinent. LVN revealed the aide was responsible daily to change the bed linens, but ultimately everyone was responsible to change the bed linens. The LVN revealed the resident last slept in her bed on 6/23/23 prior to going to the hospital. The LVN revealed if a resident goes to the hospital all lines are taken off the resident's bed and clean linens are put on the bed. The LVN revealed she made sure herself to change the linens when Resident #1 left for the hospital on 6/23/23. The LVN revealed the resident would return to the same bed. The LVN revealed the risk of leaving soiled linens could be bacteria, wounds, infections, skin compromised, hygiene issues. Interview on 6/27/23 at 1:45pm the DON revealed Resident #1 was assigned to bed 522B, but she was currently in the hospital. The DON revealed Resident #1 went to the hospital on 6/23/23. The DON revealed Resident #1 had a roommate. Resident #1 had a roommate, but the roommate was asleep each time surveyor attempted to interview her. The DON revealed Resident #1 was incontinent of bowel and bladder. The DON revealed the aides and LVNs are responsible to change the bed lines each morning and as needed. The DON revealed the last time Resident #1 slept in her bed was the night before she went to the hospital. The DON revealed the risk of leaving soiled bed linens on beds could cause infection control issues. The DON revealed the LVNs do their rounds each shift and the management team does rounds each morning. Record review of the facility Policy for Infection Control Prevention and Control Program dated, 9/2017 revealed in part: Policy Statement The infection Prevention and Control Program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. Goals: The goals of the Infection Control Program are to: a. Decrease the risk of infection to residents and personnel. b. Recognize infection control practices while providing care. c. Identify and correct problems relating to infection control practices. d. Ensure compliance with state and federal regulations relating to infection control. e. Promotion individual resident's rights and well-being while trying to prevent and control the spread of infection. f. Monitor employee health and safety.

Based on observation, interview, and record review, the facility failed to assure that medications were secure and inaccessible to unauthorized staff and residents for 1 (medication aide cart) of 4 medication carts reviewed for medication storage. The facility failed to ensure the medications were placed inside of the medication cart when MA H left the medication cart on the hallway. This failure could place residents at risk of ingesting unprescribed medications resulting in adverse health consequences. Findings included: Observation on 05/08/23 at 09:20 AM during the medication administration revealed MA H leaving the resident's medication on top of the medication cart and stated she was going to get a blood pressure machine. When MA H returned, she proceeded to the resident's room. The medications were still on top of the medication cart. There were staff members on the hallway going in an out of the residents rooms. In an interview on 05/08/23 at 09:48 AM with MA H she stated she forgot the medications on top of the cart when she left to get the blood pressure machine. MA H stated the medications were to be locked in the medication cart when she was not near the medication cart to prevent someone from taking the medications. In an interview on 05/10/23 at 12:25 PM with DON he stated MA H had informed him of leaving cards of medications on top of the medication cart when she went to another resident's room. DON stated the staff was supposed to be locking up the medication in the medication cart due to the safety because anyone can pick up the medications from the cart. DON stated he completed an in-service with all the medication aides and check off completed on medication administration. In-service reviewed. Review of the facility policy revised 05/2007 and titled Medication Administration reflected, .9. The medication cart is to be kept in clear view and in reach of the person administering medications at all times. It is to be locked when the medication nurse is away from the cart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure special eating equipment and utensils were provided for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals and snacks for 1 of 3 residents (Resident #69) reviewed for feeding assistance. The facility failed to provide Resident #69 an adaptive aid to assist her to eat independently. The failure could place residents who required adaptive feeding equipment at risk for loss of self-worth and empowerment for independent eating, which could lead to unplanned weight loss. Findings: Record review of Resident #69s quarterly MDS assessment dated [DATE] reflected Resident #69 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses unspecified severe protein-calorie malnutrition (Malnutrition is an imbalance between the nutrients your body needs to function and the nutrients it gets) Rheumatoid arthritis (A chronic inflammatory disease that affects the joints. This results in painful joints, swelling and stiffness in the joints.), pain in right arm, unspecified lack of coordination, and muscle weakness generalized. Resident #69 BIMS was 15 which indicated cognitive intact. She required limited assistance with eating. Record review of Resident #69's Comprehensive Care Plan, dated 11/10/22, reflected the following: recommend use of divided plates for all meals . Goal: maintain adequate nutritional status . Interventions: follow diet ordered by physician and aid with meals as needed. Record review of Resident #69 weights revealed on 04/02/23, the resident weighed 86.2 lbs. On 05/03/2023, the resident weighed 86.2 pounds which is a 0.00 % Gain. On 12/02/22, the resident weighed 82.6 lbs. On 05/03/23, the resident weighed 86.2 pounds which is a 4.36 % Gain. Record review of Resident #69's orders revealed divided plate with all meals ordered by phone on 04/18/2023. Resident#69 orders revealed continue total assist with meals for weight loss ordered by phone on 01/20/23. During an interview and observation on 05/08/23 at 01:00 PM Resident #69 had trouble lifting her food off her plate. I get so tried trying to eat the food off of the plate, I give up most of the time. Resident#69 stated the divided plate was helpful and she did not have to chase her food around her plate. Resident#69 stated she was having trouble today gripping her utensil and she was still hungry and liked the food. Surveyor asked Resident#69 if she wanted staff to assist her and she stated no. During observation on 05/10/23 at 08:42 AM Resident#69's plate did not have dividers and Resident#69 had orange juice and was not ready to eat her breakfast plate. During interview and observation on 05/10/23 at 08:42 AM the DON stated that Resident#69'plate did not have dividers. DON stated it was the kitchen staff responsibility to make sure residents' food was plated on the correct plate. During interview on 05/10/23 at 11:45 AM Occupational Therapist T stated patients could use the plate dividers to help lift food. Occupational Therapist T stated not having the plate dividers would not cause the resident harm, but it would make the process of eating take longer to do. Occupational Therapist T stated that Occupational Therapy and Speech Therapy work ed together to determine the residents needs and goals. Occupational therapist T stated they have tried different assistive equipment with the resident and saw what would work the best. The Dietary Manager and Charge nurse should receive printed tickets with special equipment needs noted. Occupational Therapist T stated someone is supposed to make sure she finished her meals. Occupational Therapist T stated one of Resident#69 goals are to independently feed herself. Occupational Therapist T stated the Ticket system recently changed at the beginning of last week. Occupational therapist T stated Occupational therapy made sure resident information was updated and correct. During interview on 05/10/23 at 12:05 PM, the Speech Therapist stated they usually consult ed with Occupational therapy to see what the best things for resident will be, copy of order for divided plate was given to kitchen and nursing. Speech Therapist M stated the care plan was updated with information for special equipment. Speech Therapist M stated the divided plates made it easier to eat. Speech T herapist M stated she had assisted Resident#69 with feeding her cereal and she was able to get toast on her own. During interview on 05/10/23 at 12:17 PM DON stated it would take the resident longer to finish eating if the plate did not have the dividers. The kitchen staff was supposed to check the tray to make sure residents are getting the right things. DON stated Resident#69 would have asked for help from nursing staff when she needed it. DON stated Resident#69 usually does not ask for assist. During interview and Record review a on 05/10/23 at 01:50 PM with Regional Dietitian, she stated not having the divided plates would mess up the resident by mouth intake and could cause weight loss. The Regional Dietitian stated the facility switched over to a new meal ticket system the previous week and she thought she had transferred all the information over. Record review revealed dietary instructions were in Resident#69 orders and care plan. During an interview and observation on 05/10/23 at 2:30 PM, the Dietary Manager stated dietary staff were made aware of orders for adapted devices such as divided plates for their meals. Dietary Manager stated the facility recently switched over to a new ticket system for their trays. Dietary Manager pointed to a section on the ticket titled Tray Instructions and stated any orders for things like divided plates and weighted silverware would show there. Dietary Manager stated in their other facilities, the ticket system communicated with the facility's Electronic Medical Record System-Point Click Care so orders automatically carried over. That was not the case in this facility, and they worked to correct it. Dietary Manager stated all new orders were sent to the Regional Dietitian, who manually entered all orders. She stated the Speech Therapist gave her a list of all residents requiring adaptive aides and that was sent to the Regional Dietitian as well. The Dietary Manager stated, without the dividers, the residents would be unable to get the food onto their utensil and food would wind up on the table, and not in their mouth. The Dietary Manager stated this could lead to weight loss and lack of nutrition needed for healing and well-being. Dietary Manager stated staff was in service on 05/10/23 on the new ticketing system. Record review of the facility physician orders (revised 05/2007), revealed no policy related to assistive devices.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain medical records on each resident that are complete, accurately documented and readily accessible for one (Resident #85) of five residents reviewed for clinical records. The facility failed to ensure that Resident #85's physician's orders for tramadol were written to be given orally and not enterally. This failure could place residents at risk of inaccurate medical records that could affect monitoring and medical services provided. Findings included: Review of Resident #85's face sheet, dated 05/10/23, revealed she was an [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included cognitive communication deficit, unspecified dementia, and schizoaffective disorder. Review of Resident #85's physician's orders reflected: Tramadol tablet 50 MG, give 50 MG enterally every 6 hours as needed for for lower back pain [sic] with a start date of 09/11/20. Review of Resident #85's most recent quarterly MDS assessment, dated 01/10/23, reflected she had a BIMS of 01 indicating severe cognitive impairment. An observation and interview on 05/10/23 at 12:30 PM with Resident #85 revealed she was sitting in the dining room area at a table eating her lunch. Resident #85 was not able to answer questions but there was no indication she had a g-tube. An interview on 05/10/23 at 12:35 PM with MA G revealed she did not provide Resident #85 her PRN tramadol, but that the nurse did instead. MA G said Resident #85 should receive all her medications by mouth since she did not have a g-tube. An interview on 05/10/23 at 1:10 PM with LVN T revealed Resident #85 had not been provided her PRN Tramadol for a while because she had not needed it. LVN T said that Resident #85 did not use a g-tube and should receive all her medications by mouth instead. LVN T said she had only been at the facility for a little while and was not sure why the Tramadol order was written to be given to her enterally when that was not an option for her. An interview on 05/10/23 at 1:25 PM with the DON revealed Resident #85 did not have a g-tube and should receive her medications by mouth and not enterally. The DON said he was not sure why Resident #85's tramadol was written to be given enterally instead of by mouth. The DON did not provide a concern regarding the medication order written incorrectly. Review of the facility's policy, revised 05/07, reflected: 6. Orders for medications must include: .D. Route of administration if other than oral; .

Based on observations, interview, and record review, the facility failed to handle, store, process, and transport linens so as to prevent the spread of infection for one (300-unit shower room) of four facility shower rooms reviewed for infection control. The facility failed to ensure soiled laundry and bedding was not stored in the 300-unit shower room to prevent the spread of infection. This failure could affect staff and residents placing them at risk for the spread of infection. Findings included: An observation on 03/15/23 at 8:42 AM of the 300-unit shower room revealed, assorted towels, one blanket, and a pair of resident's socks in direct contact with the shower floor. The soiled resident's laundry and bedding was not bagged. An interview and observation on 3/15/23 at 8:45 AM with the ADON revealed, he observed assorted linens, a towel, and a pair of resident's socks in direct contact with the shower room floor not bagged. The ADON stated soiled laundry should be placed in a plastic bag and then placed in a yellow bin for laundry personnel to retrieve. He stated the items in direct contact with the floor not being bagged posed an infection control issue with the potential for transmission of germs to anyone who would handle them. In an interview on 03/15/23 at 12:20 PM the DON stated, facility staff were in serviced 03/15/23 on Infection Control/Disposal of Soiled Linens. He stated they were in serviced that resident laundry and linens should be bagged in the shower room as they are completing a shower and once bagged should be placed in the yellow laundry barrel. He stated, resident laundry and linens should not be placed in direct contact with the floor due to the risk of infection control and to prevent cross contamination of dirty and clean materials. Review of the facility policy dated 08/29/17 titled Infection Prevention and Control Program Section Infection Prevention and Control Program-Linens reflected, I. Policy Soiled laundry/bedding shall be handled in a manner that prevents gross microbial contamination of the air and persons handling the linen. II. 1. Soiled laundry and bedding (e.g. personal clothing, uniforms, scrub suits, gowns, bedsheets, blankets, towel, etc.) contaminated with blood or other potentially infectious materials must be handled as little as possible and with a minimum of agitation. 2. Place contaminated laundry in a bag or container at the location where it is used and do not sort or rinse at the location of use. 3. Place and transport contaminated laundry in bags or containers in accordance with established policies governing the handling and disposal of contaminated items.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment, which included but not limited to receiving treatment and supports for daily living safely for one (Resident #1) of four residents reviewed for environment. The facility failed to ensure Resident #1's walls in her room were in good repair. This failure could place residents at risk for a diminished quality of life due to the lack of a homelike environment. Findings include: Record review of Resident #1's Annual MDS assessment, dated 02/02/23, revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included hypertension, diabetes, hyperlipidemia, schizophrenia, and Non-Alzheimer's Dementia. Her BIMS score was 0 out of 15, which revealed she was severely cognitively impaired. Observation on 03/09/23 at 11:36 AM of Resident #1's room revealed there was a hole in her wall behind the headboard of her bed. The hole in her wall was aproximately 1 ft long and 6 inches wide. Resident #1 was not at the facility during the observation and did not return prior to surveyor exiting the facility. Resident #1's RP was not contacted. Review of the monthly grievance log for December 2022 - February 2023, reflected there were no concerns regarding holes in residents' walls. Interview with the Maintenance Supervisor on 03/09/23 at 11:51 AM revealed he was responsible for facility repairs. He stated 03/09/23 was the first time he had been in Resident #1's room. He stated he had not received any maintenance requests to repair the wall in her room. He stated he did not know how long the hole had been in the wall. He stated the hole was caused by her bed being positioned too close to the wall. He stated the hole was too large to be patched. He stated he would have to replace the drywall where the hole was located. He stated the hole in the wall did not create any physical risk but was a cosmetic issue. He stated the hole in the wall did not create a home like environment for Resident #1. Interview with the Administrator on 03/09/23 at 3:29 PM revealed he was not aware there was a hole in the wall behind Resident #1's bed. He stated the Maintenance Supervisor was currently making repairs to the wall in Resident #1's room. He stated the hole in Resident #1's wall did not create a homelike environment. He stated wear and tear was normal and the facility was constantly being made. He stated his expectation was for needed repairs to be reported to the Maintenance Supervisor and for repairs to be completed. Record review of the facility policy titled Environmental Services-Housekeeping, dated November 2016, revealed Housekeeping and Maintenance services include the cleaning, sanitization, and care for rooms and common areas of the facility to ensure that the facility is safe for all who reside, work, and visit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all injuries of unknown origin were reported no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for one (Resident #1) of six residents reviewed for abuse. MA A, LVN B and LVN C failed to immediately report an allegation of suspected abuse to the abuse coordinator when they noticed bruises on Resident #1 This failure could place residents at risk for abuse and neglect. Findings include: Review of Resident #1's face sheet, dated 01/23/23, reflected the resident was an [AGE] year-old female. She was admitted to the facility on [DATE]. She was admitted with dementia, generalized anxiety, dysphagia (difficulty swallowing foods or liquids) major depressive disorder, hypertension (high or raised blood pressure), speech and language deficit and lack of coordination. Review of the quarterly MDS (Minimum Data Set) assessment, dated 12/03/22, reflected Resident #1 had a BIMS (Brief Interview Mental Status) score of 1, indicating Resident #1 had a severe cognitive impairment. She had minimal difficulty with hearing, she had unclear speech, and needed limited to extensive assistance with activities of daily living. Review of the care plan not dated reflected Resident #1 had cognitive impairment related to dementia, also indicated the resident had impaired communication related to impaired cognition. Review of the skin assessment for Resident #1, dated 01/05/23, reflected the resident had a bruise to left knee and another bruise to the right chest measuring 1cm x 1cm and the bruise was fading. In an interview on 01/23/23 at 10:18 am with MA A, he stated he had taken care of the resident. MA A stated Resident #1 was able to respond to simple commands. The resident needed extensive assistance with activities of daily living with one staff. MA A said towards the end of last month, when she was taking care of the resident, she had bruises to both breasts. He stated the bruises were medium sizes, they were in the front area of the breast. The resident did not complain of pain to the bruised area. MA A stated he was not aware what had caused the bruises. The bruises were still present, but they were fading away. When MA A stated he did not report the bruises to anyone because he assumed the bruises had been reported by the charge nurse. He stated he was aware that if a resident had bruise or injury of unknow origin, it was to be reported to the Administrator who was the abuse coordinator. An interview on 01/2/23 on 11:12 am with LVN B revealed she was the charge nurse for the resident. She stated Resident #1 was pleasant, but very confused but at times she was able to voice needs. The resident used a wheelchair to get around and she needed extensive assistance with activities of daily living. The resident was incontinent of bowel and bladder and some days she would say she wanted to use the bathroom. The resident was showered on Tuesday, Thursday, and Saturday. LVN B also stated the resident's skin assessment was completed weekly and the last time she completed the resident's skin assessment was on 01/19/23 and the resident had old bruises to the chest/breast area and left knee and the bruises were yellowish. LVN B stated the bruises on both breasts were quarter size and the bruises were spreading to the chest area but the bruise on the chest area was a small area. The staff stated she was not the one who initially noticed the bruises, but she was the one completing the weekly skin assessments because she worked in the morning shift. LVN B stated the bruises had been there since the beginning of the month. She stated she thought the bruises were caused from the resident leaning on the bedrail although she had not seen the resident leaning on the side rails. LVN B stated she did not report the bruises to anyone because they looked like old bruises. She also stated for any bruises or injury of unknown origin she was supposed to report to the Administrator because he was the abuse coordinator. An interview with LVN C on 01/23/23 at 1:30 pm revealed she had worked in the memory care unit for about 2 years on the 2-10 shift. LVN C stated she took care of Resident #1, and the resident was oriented to her name, and she was confused. She was able to follow simple commands, but she was anxious at times. She required extensive assistance with activities of daily living. She was incontinent and sometimes she will use the toilet by herself without assistance. LVN C stated Resident #1 had old bruising to bilateral lower extremities, chest areas including breast areas, no bruises on the upper thighs. She stated she noticed the bruises on the chest area around Christmas. She stated she did not report to anyone of the bruises, because she assumed it had been reported. LVN C stated the last time she saw the bruises was on 01/19/23 before the resident was being transferred to the hospital. She stated the bruises were still there, but they were yellowish, and they were fading away. Bruises on the chest area spread towards the right and left breast. The bruises were dime sized on each leg and they were yellowish. She stated the cause of breast bruises on the chest area was due to the resident pressing on the side rail when getting up. LVN C stated she had not been concerned of the resident bruises because the resident transferred herself or positioned herself in bed which might have caused the bruises. She also stated the bruises on the lower extremities could have been caused from resident hitting somewhere although LVN C had not witnessed the resident hit anywhere. She stated she was not aware if the bruises had been reported to the abuse coordinator. An interview on 01/23/23 at 1:48 pm with the ADON revealed the facility did not currently have a DON. He stated he was not aware of Resident #1 having bruises until it was reported from the hospital. He stated when he reviewed the resident's records after it had been reported that the resident had bruises, he noticed the staff had documented the resident having bruises. The ADON stated his expectation, for the staff, was to report immediately to the abuse coordinator any bruises or injury of unknown origin and then fill out an incident report. The ADON stated even if the charge nurse knew what had caused the bruise, they still had to report it. Failure of the staff to report cases of bruises, placed residents at risk of abuse. In an interview on 01/23/23 at 2:13 pm with the clinical resource nurse, she stated she had been in the facility since the DON quit, that was early this year. She stated she noticed there were some issues with documentation, communication amongst the staff members and she had completed in-services. She stated there were concerns identified with skin in the facility and there was a skin assessment on all of the residents on 01/05/23. She on 01/05/23 it was documented bruise was noted on Resident #1's chest area and knee. In-services were provided and reviewed. In an interview on 01/23/23 at 2:25pm with the Administrator, he stated he was the abuse coordinator. He stated the facility staff were to report to him, immediately, any bruises or injuries of unknown origin. He stated he was not aware Resident #1 had bruises until it was reported from the hospital. He stated after the report of the bruises, he started the investigation immediately. On 01/22/23 he completed safe surveys and none of the residents indicated being abused. He stated he also in-serviced the staff on abuse and neglect. The Administrator stated he had not reported any incident of abuse to HHS pertaining to the resident. Review of the facility policy titled Abuse: Prevention of and Prohibition Against, revised 10/2022 reflected, It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation.E. Identification. 1. Facility staff with knowledge of an actual or potential violation of this policy must report the violation to his or her supervisor or the facility administrator immediately. The facility will assist to identify abuse, neglect . 2. Because some cases of abuse are not directly observed, understanding resident outcomes of abuse can assist in identifying whether abuse is occurring or had occurred. Possible indicators of abuse include, but are not limited to: Bruises, skin tears and injuries on unknown source .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a safe, functional, sanitary, and comfortable environment for 2 (Halls 200 and 300) of 3 shower rooms and 2 (rooms [ROOM NUMBERS]) of 7 rooms observed for cleanliness. 1. The facility failed to maintain safe and sanitary conditions in restrooms for residents in rooms [ROOM NUMBERS]. 2. The facility failed to maintain safe and sanitary conditions in the shower room on Halls 200 and 300. The failure placed residents at risk for illness and decreased quality of life. Findings included: Record review of Resident #1's face sheet, dated 12/05/2022, revealed the resident was [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of legal blindness, functional quadriplegia, unsteadiness on feet, and abnormalities of gait and mobility. Record review of Resident #1's MDS assessment dated [DATE] revealed the BIMS to assess for cognitive ability was blank. Record review of Resident #2's face sheet, dated 12/05/2022, revealed the resident was [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of irritable bowel syndrome with diarrhea, unsteadiness on feet, and abnormalities of gait and mobility. Record review of Resident #2's MDS assessment dated [DATE] revealed a BIMS score of 15 indicating her cognition was intact. Observation and interview on 12/05/22 at 10:30 AM revealed near the door entrance of room [ROOM NUMBER] was a used towel, with dark brown stains, balled up on the floor. The trash can was overflowing with wipes and gloves. In the restroom, the toilet and floor was observed with dried dark matter. Resident #1 stated she could go to the restroom without assistance. Resident #1 stated she was not aware of the restroom being dirty. Observation on 12/05/22 at 12:30 PM of the shower room on Hall 300 revealed bags of trash, bags of clothing, personal items of socks, underwear, a bra, and clothing on the floor. Three bottles of shampoo and bath soap were scattered across the floor. Dried dark matter was observed in and on the toilet and on the floor from the toilet to the shower area. Dried dark matter was also observed on the bench and shower chair. Interview on 12/05/22 at 12:37 PM with CNA B revealed she had worked alone this morning and just completed her first shower of the day. CNA B stated when she entered the shower room, she observed the shower room unkept and in disarray with personal items, feces in and on the toilet and floor. CNA B stated she cleaned as much as she could with a towel and water from the shower head. CNA B stated she took a sheet and draped it over the bench and shower chair for the resident to sit in preparation for the shower. CNA B stated she was unsure whom was the last aide to use the shower room or how long it had been unkept, but she had always been trained to clean up the area after a shower which included any bodily fluids like feces and urine. CNA B stated when she finished, she looked for housekeeping to clean and disinfect the shower room however she could not locate anyone on the floor. CNA B stated it was unfair for the residents to have to shower in an unclean environment, so she tried to clean the feces with a towel and placed a sheet for her resident to sit down on to protect him from feces. Observation on 12/05/22 at 12:58 PM of room [ROOM NUMBER] revealed the toilet and floor was observed with dried dark matter. Observation revealed the restroom still had not been cleaned. Observation on 12/05/22 at 1:07 PM of the shower room on Hall 200 revealed trash, two shampoo bottles, and used toilet paper on the floor. Observation and interview on 12/05/22 at 1:10 PM revealed stuffed animals, used toilet paper, trash, clothes, and empty soda bottles on a sticky floor in room [ROOM NUMBER]. The bedside table was observed with personal items, empty coke bottles, trash, snacks and used tissues. The nightstand had multiple personal items piled against the wall to include clothing, stuffed animals, and books. The trash can was overflowing with trash. The window was observed with dust and dirt. Resident #2 stated she had not seen housekeeping in two weeks. The resident stated she would like assistance with cleaning her room. Resident #2 stated she felt uncomfortable having a messy room and had requested assistance from housekeeping and aides to help her to keep it clean. Observation further revealed Resident #2's restroom had dried dark matter on the floor and toilet, with mangled used toilet tissue with dried dark matter on the floor. When asked about the dried dark matter in the restroom, she stated she needed help to keep the restroom clean. Resident #2 stated she had not been ill and could go to the restroom without assistance. Resident #2 stated she did not recall how long dried dark matter and used toilet paper had been on the floor. During an observation and interview on 12/05/22 at 1:38 PM, Housekeeping Aide A revealed he was responsible for working on Hall 200 and sometimes helped on Hall 500. Housekeeping Aide A stated he cleaned resident rooms daily and shower rooms twice a week because they did not get that dirty. Housekeeping Aide A stated when cleaning resident rooms he swept and mopped the floors, wiped high touch areas, wiped the sink and commode. Housekeeping Aide A stated he last cleaned Resident #2's room on last Friday which was three days ago. Housekeeping Aide A stated Resident #2 would do stuff like put trash and used toilet paper all over the place. Housekeeping Aide A stated he sometimes found feces Resident #2's restroom. Housekeeping Aide A stated when cleaning her room, he usually had to do a deep cleaning. When asked about housekeeping on other halls he stated the Housekeeping Supervisor was working on Halls 100 and 300 and two other aides were working Halls 400 and 500. Observation on 12/05/22 from 1:56 PM - 2:01 PM of room [ROOM NUMBER] and Hall 300 shower room revealed no changes and neither had been cleaned. During an interview on 12/05/22 at 3:19 PM, CNA C revealed when she saw feces or the need to clean resident rooms, she would do the cleaning. CNA C stated she did not wait on housekeeping to come in and do the cleaning. She stated she would clean the feces, sweep, clean the floors. If there was something that needed to be disinfected or deep cleaned, she would let housekeeping know about it. CNA C stated it was her responsibility to ensure residents were in a safe clean environment. CNA C stated she was unaware there was a used dirty towel and feces in room [ROOM NUMBER]'s restroom. CNA C stated Resident #1 would go to the restroom on her own and it was hard to tell if she needed help. CNA C stated when she had gone to check on her Resident #1 was in bed and never said anything about going to the restroom. Observation and interview on 12/05/22 at 3:55 PM with the Housekeeping Supervisor revealed he was also the Van Driver and Central Supply Coordinator. The Housekeeping Supervisor stated everyone has their own halls which includes shower rooms to clean daily. The Housekeeping Supervisor stated today he was responsible for Halls 100 and 300. He was also responsible for taking residents to appointments. He stated he did not expect to have this many appointments today which prevented him from cleaning the halls in a timely manner. He stated if there were any bodily fluids, feces, or personal items on the floor CNAs were supposed to do the initial cleaning and notify housekeeping to deep clean. During an observation of the 300 Hall shower room revealed bags of trash, bags of clothing, personal items of socks, underwear, a bra, and clothing on the floor. Three bottles of shampoo and bath soap were scattered across the floor. Dried dark matter was observed in and on the toilet and on the floor from the toilet to the shower area. Dried dark matter was also observed on the bench and shower chair. The Housekeeping Supervisor stated he was unaware of the shower room with feces and that it needed to be cleaned. He stated he would have expected the nursing staff or CNAs to report the situation. The Housekeeping Supervisor stated the situation puts residents at risk of disease and illness by having them shower in an unsanitary condition. Observation and interview on 12/05/22 at 4:20 PM with the DON, in the shower room on Hall 300, revealed the floor had feces from the toilet to the shower. There were residents' personal items to include a bra, underwear, socks, and trash on the floor. The DON stated the shower room was unacceptable for residents to shower in. The DON stated he expected the CNAs to pick up after themselves and residents throughout the day after care. The DON stated it was the nursing staff and his responsibility to ensure residents are living in a safe environment. The DON stated leaving the shower room with feces on the floor and individual personal items that belong to others could spread infection and virus from one person to the next. During an interview on 12/05/22 at 5:20 PM, the Administrator stated they had a very difficult population at the facility. He stated with the resident population it would be hard to prevent some things such as keeping feces off the toilet. He stated Resident #1 was blind, ambulatory, and did not use her call light; therefore, it would be hard to know if she had an accident that needed to be cleaned right away. The Administrator stated Resident #2 did not typically let anyone touch her personal items so it would be hard to keep her room clean. The Administrator stated it was the responsibility of the housekeeping staff to ensure all rooms and shower rooms were disinfected and cleaned for resident use and not doing so would create illness throughout the facility. Record review of facility's Environmental Services - Housekeeping policy, revised November 2016, reflected the following: .Housekeeping services include the cleaning, sanitization, and care for rooms and common areas of the facility to ensure that the facility is safe for all who reside, work, and visit. All rooms of residents will be cleaned regularly by sweeping and mopping room and restroom, Clean with disinfectant high touch areas such as doorknobs, tray stands, sink, toilet, mirror, and floor. Declutter the room by picking up and changing the trash.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents received adequate supervision and assistance devices were put into place prevent accidents for one (Resident #60) of five residents reviewed for falls. The facility failed ensure Resident #60's floor mat was on the floor, next to her bed to prevent potential fall injury. This failure could place the resident who require supervision assistance due at risk for falls with injuries, hospitalization and a decreased quality of life. Findings included: Review of Resident #60's quarterly MDS assessment, dated 01/20/22, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with active diagnoses of abnormal posture, bipolar disorder, lack of coordination, fatigue, history of falling, abnormalities of gait and mobility, anxiety disorder, muscle weakness, dementia. She had signs of delirium which included fluctuating disorganized thinking and continuously present altered levels of consciousness. Resident #60 rarely understood when spoken to, which indicated she was not able to follow commands. According to Resident #60's MDS, she was totally dependent for bed mobility and transfers. Resident was not able to mobilize, unless using a wheelchair, with the assistance of staff. Review of Resident #1's care plan, undated, reflected the resident was high risk for falls, impaired cognition, decreased mobility and weakness. The goal for the resident was, Not sustain any injury through the review date. The interventions for Resident 60 were, Call light within reach, bed in the lowest position and fall mat at bedside. Review of Resident 60's clinical progress note, dated 01/27/22, revealed the resident was total care and wheelchair bound. Observation on 03/22/22 at 2:46 PM revealed, Resident #60 was lying in bed. Her bed was in low position. Resident's floor mat was not at bedside. The floor mat was in between the wall, next to the window and the resident's dresser. An interview with the DON on 03/24/22 at 10:00 AM, revealed she ensured staff were following a resident's care plan by conducting rounds. She stated staff should review the resident's chart prior to providing care to ensure the resident was receiving the appropriate care by staff. DON stated there were Angel rounds conducted as well, which would allow people assigned to a particular room to check on the resident. DON stated she would also have daily meetings, which would allow staff time to discuss residents' care to ensure the care plans were being followed. DON stated Resident #60 was considered a high risk for fall and stated it was documented in the resident's care plan. DON stated the purpose of a care plan was to identify potential areas which were tailored based on the resident's needs. She stated the purpose of care plans was to also aide the nursing staff with providing the proper care to a resident. DON stated she expected all staff to follow residents' care plan. DON stated she was familiar with Resident #60 and stated the resident was considered a high risk for falls. DON stated the resident should have had a fall mat beside her bed while she was in bed. She stated she did not know why the fall mat was not in place and stated she would have to follow up. She stated the purpose of the fall mat was to soften a fall to prevent injury. DON stated the potential risk of a fall would be, fractures to hips, head injury, skin tear, bruises, fear of falling and not feeling safe. She stated Resident #60's last fall was in the month of October 2021. An interview with CNA I on 03/24/22 at 11:30 AM, revealed nursing staff were able to determine if a resident was a fall risk and determine if interventions were in place by reviewing the resident's care plan. CNA I stated staff should review the resident's care plan prior to providing care. CNA I stated for a fall resident, the bed would be in a low position and a fall mat would be in place, next to the resident's bed. She stated Resident #60 had not had a fall since, she had been providing care to her and stated she had never witnessed the resident attempting to get out of bed. CNA I stated the resident was not able to get out of bed without assistance. She stated Resident #60 was not able to walk and was total dependent on a wheelchair. CNA I stated a floor mat was supposed to be on the floor next to the resident's bed due to the resident being a high fall risk and it being care planned. An interview with the Administrator on 03/24/22 at 2:06 PM revealed, he expected, All staff to follow a resident's care plan with fidelity. He stated the care plans are in place to help the resident and to provide the most practicable quality life and care a resident need. Administrator if a resident was a fall risk, he would expect for all fall preventions to be followed. He stated the purpose of fall prevention and/or interventions was to prevent falls. Review of the facility's fall Management system, revised 06/2018, The facility is committed to promoting resident autonomy by providing an environment that remains as free of accident hazards as possible. Each resident is assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision, assistive devices and functional programs as appropriate to prevent accidents. It is the policy of this facility to provide each resident with appropriate assessment and interventions to prevent fall and to minimize complications if a fall occurs .2. Residents with high risk factor identified on the Fall Risk Evaluation will have an individualized care plan developed that includes measurable objectives and timeframes. The care plan interventions will be developed to prevent falls by addressing the risk factor and will consider the particular elements of the evaluation that put the resident at risk.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent. There were 4 errors out of 47 opportunities, resulting in an 8 percent medication error involving for 3 (Resident #70, #81 and #69) of 5 residents reviewed for medication errors. 1. MA H failed to administer Lisinopril 2.5 mg to Resident #70 during medication administration 2. MA H failed to follow physician orders to administer chewable Aspirin 81 mg, instead MA H administered Aspirin low dose enteric coated 81 mg to Resident # 81 3. MA H failed to administer Magnesium oxide to Resident #81 during medication administration 4. MA H failed to administer Oxybutynin to Resident #69 during medication administration These failures could place residents at risk for inaccurate drug administration and cause adverse reaction to residents if medications are not taken as directed. Findings included: Record review of a face sheet dated 3/24/22 revealed Resident #70 was a [AGE] year-old female that was admitted on [DATE] with diagnoses of diabetes mellitus, Parkinson's disease, hypertension, pain to right hip, gastro-esophageal reflux disease episodes and dysphagia. Record review of Resident #70's physician's orders and medication administration record dated 3/24/22 revealed the following medications were scheduled to be administered in the morning; Aspirin enteric coated tablet delayed release 81 mg, bumex 1 mg tablet, docusate sodium 100 mg tablet, lisinopril 2.5 mg tablet, magnesium oxide 400 mg tablet, neupro patch, sertraline HCL 25 mg tablet, vitamin D3 125 mcg tablet, mamentine 10 mg, metformin HCL 500 mg tablet. Observation on 03/23/22 at 8:00 AM revealed MA H administered the following medications to Resident #70; Vitamin D-3 125 mcg (500 in) 1 tablet, stool softener 100 mg 1 tablet, Low dose enteric coated Aspirin 81 mg 1 tablet, Bumetanide 1 mg 1 tablet, Magnesium oxide 400 mg 1 tablet, Mamentine 10 mg 1 tablet, Metformin 500 mg 1 tablet with food, Sertraline 25 mg 1 tablet, Neupro 4mg/24hrs 1 patch. Record review of medication reconciliation using the physician orders for Resident # 70 dated 3/24/22 revealed CMA H failed to administer Lisinopril 2.5 mg to Resident #70. Record review of a face sheet dated 3/24/22 revealed Resident #81 was a [AGE] year-old male that was admitted on [DATE] with diagnosis of hypertension, major depressive disorder, hemiplegia, aphasia, hyperlipidemia, and cerebral infarction. Record review of Resident # 81's physician orders and medication administration record dated 3/24/22 revealed the following medications were to be administered in the morning; Memantine 5 mg 1 tablet, Glimepiride 2 mg 1 tablet after breakfast, Metoprolol Succinate 25 mg extended-release half tablet, Allopurinol 300 mg 1 tablet, Chewable Aspirin 1 mg 1 tablet, acidophilus 1 capsule, Metformin 1000 mg 1 tablet, Venlafaxine 75 mg 1 tablet, Lisinopril 30 mg 1 tablet, Multi-vitamin supplement 1 tablet, Amlodipine 5 mg 1 tablet and magnesium oxide 400 mg 1 tablet. Observation on 03/23/22 at 8:20 AM revealed MA H administered the following medications to Resident #81; Memantine 5 mg 1 tablet, Glimepiride 2 mg 1 tablet after breakfast, Metoprolol Succinate 25 mg extended-release half tablet, Allopurinol 300 mg 1 tablet, Aspirin 81 mg enteric coated 1 tablet, acidophilus 1 capsule, Metformin 1000 mg 1 tablet, Venlafaxine 75 mg 1 tablet, Lisinopril 30 mg 1 tablet, Multi-vitamin supplement 1 tablet and Amlodipine 5 mg 1 tablet. Record review of medication reconciliation with Resident #81's physician orders reflected MA H failed to administer Magnesium oxide 400 mg 1 tablet and administered Aspirin 81 mg enteric coated instead of Aspirin 81 mg chewable 1 tablet. Record review of Resident #69's face sheet revealed he was 88 years-old male that was admitted on [DATE] with diagnosis of; dementia, obstructive and reflux pulmonary disease, hypertension, acute kidney disease, and benign prostatic hyperplasia with lower urinary tract symptoms. Record review of Resident #69's physician orders and medication administration record dated 3/24/22 revealed the resident was taking the following medication: Aspirin chewable 81 mg 1 tablet, Vitamin D 25 mcg 1 tablet, Finasteride 5 mg 1 tablet, Vitamin C 500 mg 1 tablet, Memantine10 mg 1 tablet, Vitamin B-12 500 mcg, Doxazosin 4 mg 1 tablet, polyethylene glycol 17gram, Multi-Vitamin 1 tablet and Oxybutynin chloride 5 mg 1 tablet. Observation on 2/23/22 at 8:50 AM, revealed MA H administered the following medications to Resident #69; Aspirin chewable 81 mg 1 tablet, Vitamin D 25 mcg 1 tablet, Finasteride 5 mg 1 tablet, Vitamin C 500 mg 1 tablet, Memantine10 mg 1 tablet, Vitamin B-12 500 mcg, Doxazosin 4 mg 1 tablet, polyethylene glycol 17 gram and Multi-Vitamin 1 tablet Record review of medication reconciliation with Resident #69's physician orders revealed MA H failed to administer Oxybutynin chloride 5 mg 1 tablet to Resident #69. In an interview on 3/24/22 at 12:05 PM with MA H revealed she was not aware that she did not administer the following medications; Oxybutynin 5 mg to Resident #69, magnesium oxide 400 mg and Aspirin 81 mg chewable to Resident #81 and Lisinopril 2.5 mg to Resident #70 because she already had the medications in the cart. She stated she did not know how she missed the medications because she completed the medication count with matched with the number observed during the medication administration. She stated she was expected to follow the 5 rights for medication administration and physician orders during medication administration. She stated failure to administer medications per the orders could have a negative effect on the resident, like the resident who missed the blood pressure medication could have increased blood pressure. In an interview on 03/24/22 at 1:18 PM with the DON she stated, she expected the staff to verify the orders in the medication administration record and administer medications per order, also administer medication per the instructions in the orders. DON stated if there was any question about an order, the MA was expected to ask the nurse in charge. The DON stated the medications were to be administered per the orders for the safety of the resident and to prevent error which may lead to illness and death. The DON stated she was responsible to monitor and make sure the staff were following the five rights. Review of the facility policy revised 05/2007 and titled, Medication Administration reflected, It is the policy of this facility that medications shall be administered as prescribed by the attending physician .2. Medications must be administered in accordance with the written orders of the attending physician

Based on observation, interview, and record review, the facility failed to date and store foods in accordance with the professional standards for food service safety in the facility's only kitchen reviewed for safety requirements. The facility failed to ensure food items in the refrigerator were dated appropriately. This failure could place residents at risk for food-borne illness and cross contamination. Findings included: Observation of the kitchen's refrigerator on 03/22/22 at 9:30AM revealed the following: -1/2 of a tomato that had been cut into/sliced and wrapped in plastic wrap, which was not dated -1 storage container of leftover tuna salad that had been previously opened and resealed, which was not dated with the date the container had been originally opened During an interview with the Dietary Manager on 03/22/22 at 9:30AM, she stated the tomato in the refrigerator should have been dated upon dietary staff cutting into and using the tomato. She then threw the tomato away. She stated the container of tuna salad had been originally opened and served the day prior, 03/21/22, and she said the container should have been dated at that time. During a subsequent interview with the Dietary Manager on 03/24/22 at 9:45AM, she stated she did not feel there was a risk of the tomato not being labeled or dated, or the tuna salad leftovers not being dated. She stated staff were able to tell when food items became soiled and that there was still a manufacturer's expiration date on the container of tuna salad. Review of the facility's Dietary Services policy and procedure, revised 05/2007, reflected, .It is the policy of this facility to prevent contamination of food products and therefore prevent foodborne illness . The policy reflected, .Procedures: 1. Director of Food Service Responsibilities . F. Provide for the proper receipt and storage of all food supplies . The policy also reflected, .6. Proper Food Handling: . K. Leftovers must be dated, labeled, covered, cooled and stored (within ½ hour) in a refrigerator . Review of the U.S. Public Health Service Food Code, 2017, reflected, Food Establishment and if the Food is held for more than 24 hours, to indicate the date or day by which the Food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and:(1) The day the original container is opened in the Food establishment shall be counted as Day 1; and (2) The day or date marked by the Food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on Food safety. 3) Marking the date or day the original container is opened in a Food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the Regulatory Authority upon request.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of infectious diseases and infections for 3 (CNA A, CNA B, and COTA E) of 5 staff members and 3 (R#56, R#1, and R#74) of 5 residents observed for infection control. 1) The facility staff failed to assist one resident (Resident #56) with hand hygiene before lunch. 2) The facility staff failed to ensure two residents (Resident #1 and Resident #74) performed hand hygiene appropriately after using the restroom where soap or ABHR was not readily accessible to the resident. 3) CNA A and CNA B failed to perform hand hygiene between contact with residents and handling dirty plates during mealtime. 4) COTA C was observed exiting the rehab gym wearing gloves and removed gloves while walking in the hallway without performing hand hygiene afterward. These failures could place the residents at risk for infections. Findings included: An observation on 03/22/2022 of Hall 500, a secured, locked unit (Memory Care) for residents with Alzheimer's disease and other forms of dementia, revealed hallways that did not have wall-mounted alcohol-based hand rub (ABHR) readily available for staff to use. Wall-mounted ABHR or individual bottles of alcohol-based hand rub (ABHR) was not at an entry or exit point of a resident's room. There was no soap, paper towels, or tissue paper in the resident's bathrooms. Observation on 03/22/2022 at 11:41 AM revealed the bathroom in room [ROOM NUMBER] had a wet, soiled washcloth in the sink. There was no soap in the dispenser, tissue paper, or paper towels. During observation and interview on 03/22/2022 at 11:50 AM, Resident #1 exited her restroom after voiding. Resident #1 has a diagnosis of Alzheimer's/Dementia and a BIMS score of 15 - intact cognitive response; stated the bathroom did not have tissue paper, soap, or paper towels. Resident #1 denied using soap and water or an ABHR to wash her hands after using the restroom and said, just rinse my hands, when asked about how she washed her hands without soap. Observation of Resident #1's bathroom did not have soap, paper towels, or tissue paper available. The resident pulled the door to her room closed and walked towards the dining room. The resident held on to the handrail while ambulating down the hall. The rail is a highly touched surface. An observation on 03/22/2022 at 12:07 PM of Hall 500 dining room during lunchtime revealed residents assisted to the dining table. Resident #56 has a diagnosis of Alzheimer's/Dementia was wandering the halls, touching other residents, high-touched surfaces such as rails and walls before sitting at a table and served lunch. The staff did not help Resident #56 with hand hygiene before the meal. A review of the Appendix PP Standard Precautions indicated: .evidence-based practices are designed to protect healthcare staff and residents by preventing the spread of infections among residents and ensuring staff does not carry infectious pathogens on their hands . standard precautions include hand hygiene If residents need assistance with hand hygiene, staff should assist with washing hands after toileting, before meals, and using ABHR or soap and water at other times when indicated. During an interview on 03/22/2022 at 12:09 PM, LVN F indicated that staff check resident bathrooms daily for soap, tissue, and paper towels. When informed that rooms were observed not having hand hygiene supplies in the bathroom, LVN F replied that this [Hall 500] was a dementia unit and they do not provide soap, tissue, and paper towels because residents clog the sink and toilets or may try to eat the soap. LVN F continued to state that most residents on the unit were incontinent of bowel and bladder. When asked how staff performs hand hygiene after assisting a resident with incontinence care, LVN F replied that there was hand sanitizer at the nursing station, or staff could go to the bathroom by the nursing station to wash their hands. Continent residents will ask staff for tissue, and we will give it to them. Observation and interview on 03/22/2022 at 2:20 PM revealed COTA E was exiting the rehab gym wearing disposable gloves. Upon eye contact, COTA E removed the gloves and placed them in his pocket without performing hand hygiene. During an interview, COTA E stated that he was supposed to change gloves between resident care and perform hand hygiene with ABHR or use soap and water. COTA E said that he should have removed the gloves before exiting the rehab gym and used ABHR or soap and water before leaving the gym. COTA E stated that not changing his gloves or keeping them on between halls/units risks the spread of infection. During an interview on 03/22/2022 at 2:33 PM on Hall 500, HK stated being responsible for cleaning the resident's rooms and providing soap, tissue paper, and paper towels as needed. HK stated she tries to wipe down frequently touched surfaces everyday like doorknobs, rails, and the counter at the nursing station. The ADON said that soap, tissue paper, and paper towels were not supplied in Hall 500 because the residents took the tissue and clogged up the toilet. Assisting residents with hand hygiene is advocated by The Centers for Disease Control and Prevention (CDC, 2020) guidance related to infection control in units where there are residents with cognitive impairments . can have a difficult time following recommended infection prevention practices such as social distancing, washing their hands, avoiding touching their face . The CDC recommend frequently cleaning often-touched surfaces in the memory care unit, especially in hallways and common areas where residents and staff spend a lot of time (CDC, 2020). During an interview on 03/22/2022 at 2:35 PM on Hall 500, the ADON gave an example of a time Resident #1 took the tissue paper and tore one piece at a time, tossing it into the toilet, and it had to be unclogged by maintenance. The ADON said soap is not filled in the dispenser in the resident bathroom because the residents can put it in their mouths. When asked about how staff performs hand hygiene after providing incontinence care, the ADON stated that when the individual gathers supplies, they also fill a small cup of soap to take with them to wash their hands. During an interview on 03/22/2022 at 3:10 PM, CNA D stated that most residents she assists can pivot and transfer to the toilet with assistance. CNA D said that she collected all the supplies needed to assist incontinent residents, rinsed her hands off with water, and wash her hands in the bathroom next to the nursing station. CNA D said that she could not use hand sanitizer immediately after because the ABHR dispensers are only in the nursing station or one in the dining area. Observation on 03/23/2022 at 10:31 AM revealed CNA B prepared to provide incontinence care to a resident. CNA B entered the bathroom, reached into her left scrub top pocket, pulled out a 7.5 fl. oz liquid hand soap pump, and performed hand hygiene. While CNA B was washing her hands, CNA G was showering a resident in the bathroom. After watching CNA B appropriately perform incontinence care, perform hand hygiene with ABHR after changing gloves, and perform hand hygiene with soap and water, CNA G assisted the resident out of the bathroom to the bedside. CNA G returned to the bathroom, still wearing the same gloves, and picked up the used towels and dirty clothes. CNA G placed the soiled items in a clear plastic bag, exited the room, walked down the hall to the soiled utility room, opened the door, disposed of the plastic bag in a bin, then removed and discarded the gloves. CNA G was about to enter room [ROOM NUMBER] when the surveyor stopped and asked about standard precautions and hand hygiene after providing direct care. CNA G pulled a 7.5 fl. oz liquid hand soap pump from her pocket and stated that she used it to wash her hands. The pump was still in a locked-down position. When asked about the facility's expectations about wearing gloves in the hallway after providing direct care, CNA G said she washed her hands after showering the resident and should not wear gloves in the hallway after providing care to a resident. Observation of Hall 500 dining on 03/24/2022 at 12:31 PM revealed CNA A collecting and placing resident's trays, silverware, and cups in a dirty dish bin, without gloves. She poured and served a resident a cup of juice without hand hygiene between contact with used dishes, the drink pitcher, or residents. On 03/24/2022 at 12:35 PM, Resident #74 was observed exiting her bathroom and walking out of her room, touching frequently touched surfaces - rails, pushing on the access keypad to the doors separating the adjoining hall, and then sitting at a dining table. Observation of Resident #74's bathroom did not reveal soap in dispenser, personal hygiene toiletries, or paper towels. Hand sanitizer is not available in resident hallways in this unit (Hall 500 - Memory Care Unit). During an interview on 03/24/2022 at 12:40 PM, CNA A stated that she uses the wall-mounted ABHR in the hallways and each time she enters and exits a resident room. When asked how hand hygiene was performed after providing incontinence care, CNA A stated that all her residents were continent. If she had to assist with incontinence care would perform hand hygiene after removing gloves. Then use hand sanitizer on the way out (demonstrated by placing a hand under a wall-mounted ABHR device) of the resident room, sanitize her hands using the sanitizer in the hallway, and then wash her hands with soap and water in the staff bathroom near the nursing station. When informed that there was no soap in the resident rooms or wall mounted ABHR in the rooms or resident hallways, CNA A patted her pockets as if looking for something, stated that she didn't know where her hand sanitizer was, and stated, Well, there isn't much I can do about that. CNA A said she was never provided a bottle of hand soap to carry around in her pocket on Hall 500 for hand hygiene. On 03/24/2022, at approximately 12:45 PM, an interview with CNA B indicated that when asked about assisting residents with hand hygiene after using the restroom, using Resident #74 as an example, CNA B replied that Resident #74 had her own soap and knew to wash her hands. CNA B was asked, How are residents reminded to perform hand hygiene after toileting and before meals? CNA B replied that Resident #74 knows to wash her hands but could not provide an answer to the question. In an interview on 03/24/2022 at 1:00 PM, the DON/Infection Preventionist revealed she purchased pump soap for staff to carry in pockets for hand hygiene before and after incontinent care in the residents' room at the end of the day on 03/22/2022 after surveyor interaction. The DON verbalized hand hygiene as the primary means to prevent the spread of infection. The DON stated that she expected staff always to have ABHR in their pockets since Hall 500 does not have wall-mounted ABHR in the resident hallways. The DON denied training agency staff before assigning them to Hall 500 (a memory care unit). However, she explained that she posted QR codes at the entry door for the COVID unit when being used for staff to scan and access policy and procedures and information about infection control. A review of an updated written facility policy titled Prevention of Infection IPCP - Hand Hygiene established that an ABHR containing at least 62% alcohol; alternatively, soap and water before and after direct contact with residents or contact with a resident's intact skin; after removing and disposing of PPE; after handling soiled items; or when in contact with objects near the resident. Ref: Centers for Medicare and Medicaid Services (CMS). (2017). Standard precautions. State Operations Manual for Long-term Care Facilities Appendix PP Guidance to Surveyors. https://www.cms.gov/medicare/provider-enrollment-and-certification/guidanceforlawsandregulations/downloads/appendix-pp-state-operations-manual.pdf Ref: Centers for Disease Control and Prevention. (2020, May 12). Considerations for memory care units in long-term care facilities. Retrieved on 04/07/2022: https://www.cdc.gov/coronavirus/2019-ncov/hcp/memory-care.html